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Sunday, April 12, 2015

Sexually Transmitted Infections: How Gender Inequality Affects Health

Being born a white female in Canada automatically makes you privileged.

Being born a white female in Canada, with educated parents who have stable jobs is like winning the genetic lottery.

Prior to coming to Zambia, I had been taught about gender inequality in various university classes but I was not prepared for the way I would witness it in OPD (Outpatient Department) this week.

The OPD FastTrack Register where patient information is logged for statistical purposes.

I was working with Kwibisa (an incredibly intelligent and compassionate medical officer) in area of OPD known as Fast Track or High Cost Clinic. The patients that come through this area have medical insurance and have a higher level of education than the average population. Many of the patients who we saw this week had come in for treatment of sexually transmitted infections (STIs). The kicker? They were all smart, strong, professional women who should be empowered but aren't.

Kwibisa explained that most of the patients who come in to be treated for STIs are women because STIs present differently in men and women due to anatomy. In men, the incubation period is 2-3 days while the incubation period in women can be from 14-21 days. If the man becomes symptomatic, (not all STIs are symptomatic) he will often seek treatment without telling his partner. If the woman develops symptoms, she will go seek treatment alone, if permitted by her husband or partner, leaving the woman to suffer from the stigma and shame. Often by the time the woman is showing symptoms, the husband or partner has already recontracted the infection from her or one of his other partners, causing a chain of infection that is very difficult to break.

According to the World Health Organization, 1 in every 2 deaths of adult women in their reproductive years in low income countries such as Zambia is attributed to preventable diseases such as HIV/AIDS, malaria and tuberculosis. It is important to consider the fact that tuberculosis is an opportunistic infection that is commonly contracted by people who are HIV positive so those are dying from tuberculosis are likely, in essence, dying from HIV/ AIDS as well. Furthermore, an analysis of the underlying risk factors contributing to the death of women in their reproductive years showed that unsafe sex is a leading risk factor with 23% of women's deaths attributable to unsafe sexual practices. In contrast, the leading risk factor for death in high income countries such as Canada for the same age/gender group is alcohol use. It is also important to note that females aged 15-24 are twice as likely to be HIV positives than their male counterparts.

Why are women at such risk? The answer is gender inequality, disempowerment and a lack of education. In Zambia, women are often taught to never refuse their husbands or insist that a condom be used. Girls become sexually active at age 15 or younger with men who are 5-10 years older and who have had multiple sexual partners. Infidelity is also quite common in Zambia, and although they will usually only marry one person, it is not uncommon to have several partners on the side.

As you can imagine, the health providers here have their work cut out for them. One strategy currently being used is to delay the start of treatment until the woman's partner comes in with her. This is difficult for me to wrap my head around because it seems like the woman's health is being held ransom, and if STIs aren't treated quickly they can cause serious complications, like secondary infertility. At the same time, after living in this country, I can see how this strategy could be effective. If both partners come in, you can provide thorough education about safe sex and STI prevention. It is also very important to note, that it is not that the men don't care about the health of their partners. They do, which is why they will come in if treatment is withheld. It's a lack of education and a fear of social stigma keeping them away and driving this sexual health crisis.

The room in OPD where Kwibisa and I saw patients this past week.

Because Zambia is a low-resourced country STIs are managed differently here than they are in Canada. In Canada, you would get tested if you had symptoms of an STI or if there was a possibility that you had contracted one. In middle or low income countries, they rely on a method of treatment known as syndromic management (WHO, 2013). In syndromic management, the STI is identified by its symptoms instead of a laboratory test. For example, when examining a patient for a potential STI in OPD this week, we looked at the colour and quality of the drainage to help us identity the specific infection. This method of treatment is beneficial to patients in countries like Zambia because it ensures they get rapid treatment of their condition. Many patients must walk several hours to get to the nearest medical clinic and making several trips to get lab results isn't feasible. The downside of Syndromic Management is that it increases the chance of a STI being misidentified and treated with the wrong antibiotic causing increased incidence of antibiotic resistance organisms.

I am hopeful that one day through education and advocacy women in Zambia will be able to stand up for their own sexual health and the prevalence of HIV/AIDs and STIs will decrease. Until then, I am thankful that there are health care providers like Kwibisa who are able to advocate for these women in a professional and safe way. I have learned that change is a slow process and sometimes all you can do is bear witness to things that make you uncomfortable. This isn't enough, but sometimes it has to be.